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18-016 Raney Planning & Management, Inc., an Initial Study for the Bubb Rd Project
CITY OF g PROFESSIONAL/CONSULTING SERVICES AGREEMENT CUPERTINO 1. PARTIES This Agreement is made and entered into as of January 10, 2018 ("Effective Date") by and between the City of Cupe11ino, a municipal corporation ("City "), and Raney Planning & Management, Inc . ("Contractor"), a Corporation for an Initial Study for the Bubb Road ro'ect 2. SERVICES Contractor agrees to provide the services and perfonn the tasks ("Services") set forth in detail in Scope of Services, attached here and incorporated as Exhibit A. 3. TIME OF PERFORMANCE 3.1 This Agreement begins on the Effective D ate and ends on June 30, 2018 ("Contract Time"), unless terminated earlier as provided herein. Contractor's Services shall begin on January 10 , 2018 and shall be completed by_Jt_m_e_3_0--',_2_0_1_8 _____ _ 3.2 Schedule of Performance. Contractor must deliver the Services in accordance with the Schedule of Perfo1mance, attached and incorporated here Exhibit B . 3.3 Time is of the essence for the perfonnance of all the Services. Contractor must have sufficient time, resources, and qualified staff to deliver th e Services on time . 4. COMPENSATION 4.1 Maximum Compensation. City will pay Contractor for satisfactory perfo1mance of the Services an amount that will based on actual costs but that will be capped so as not to exceed $9 100 .00 ("Contract Piice"), based upon the scope of services in Exhibit A and the budget and rates included in Exhibit C, Compensation attached and incorporated here. The ma ximum compensation includes all expenses and reimbursements and will remain in place even if Contractor's actual costs exceed the capped amount. No extra work or payment is permitted without prior written approval of City. 4.2 Invoices and Payments . Monthly invoices must state a description of the deliverable completed and the amount due for the preceding month . Within thi11y (30) days of completion of Services, Contractor must submit a requisition for final and complete payment of costs and pending claims for City approval. Failure to timel y submit a complete and accurate payment requisition relieves City of any fmther payment or other obligations under the Agreement. C ity Projec t/Program_B_u_bb_R_o_a_d_P_roJ~·e_ct _______________________ _ Profess ional/Cons ulting Contracts /Rev. Nov 16, 20 17 Page I of9 5. INDEPENDENT CONTRACTOR 5 .1 Status. Contractor is an independent contractor and not an employee, partner, or joint venture of City. Contractor is solely responsible for the means and methods of perfonning the Services and for the persons hired to work under this Agreement. Contractor is not entitled to health benefits , worker 's compensation or other benefits from the City . 5 .2 Contractor's Qualifications. Contractor waiTants on behalf of itself and its subcontractors that they have the qualifications and skills to perform the Services in a competent and professional manner and according to the highest standards and best practices in the industry. 5.3 Permits and Licenses. Contractor wan-ants on behalf of itself and its subcontractors that they are properly licensed , registered , and/or ce1tified to perfonn the Services as required by law and have procured a City Business License . 5.4 Subcontractors. Only Contractor's employees are authorized to work under this Agreement. Prior written approval from City is required for any subcontractor, and the terms and conditions of this Agreement will apply to any approved subcontractor. 5.5 Tools, Materials and Equipment. Contractor will supply all tools, materials and equipment required to perfmm the Services under this Agreement. 5 .6 Payment of Taxes. Contractor must pay income taxes on the money earned under this Agreement. Upon City 's request, Contractor will provide proof of payment and will indemnify City for violations pursuant to the indemnification provision of this Agreement. 6. PROPRIETARY/CONFIDENTIAL INFORMATION In performing this Agreement , Contractor may have access to private or confidential info1mation owned or controlled by the City, which may contain proprietary or confidential details the disclosure of which to third paities may be damaging to City . Contractor shall hold in confidence all City information provided by City to Contractor and use it only to perfonn this Agreement. Contractor shall exercise the same standard of care to protect City info1mation as a reasonably pmdent contractor would use to protect its own prop1ietary data. 7. OWNERSHIP OF MATERIALS 7.1 Property Rights. Any interest (including copyright interests) of Contractor in any product, memoranda, study, repo1t , map , plan, drawing, specification, data, record , document or other infonn ation or work , in any medium (collectively, "Work Product"), prepared by Contractor in connection with this Agreement will be the exclusive property of the City and shall not be shown to any third-party without prior written approval of City. C i ty Proj ect/Progra m_B_u_b_b_R_oa_d_P_ro~~e_c_t ------------------------- Professional!Co nsulti11g Contra cts /Rev. Nov 16, 20 I 7 Page 2 of9 7.2 Copyright. To the extent pe1mitted by Title 17 of U.S. Code, all Work Product arising out of this Agreement is considered "works for hire " and all copy1ights to the Work Product will be the prope1iy of City . Alternatively, Contractor assigns to City all Work Product copyiights. Contractor may us e copies of the Work Product for promotion only with City's written appro v al. 7.3 Patents and Licenses. Contractor must pay royalties or license fees required for authorized use of any third party intellectual property, including but not limited to patented, trademarked, or copyrighted intellectual prope1iy if incorporated into the Services or Work Product of this Agreement. 7.4 Re-Use of Work Product. Unless prohibited by law and without waiving any rights, City may use or modify the Work Product of Contractor or its sub-contractors prepared or created under this Agreement, to execute or implement any of the following : (a) The original Services for which Contractor was hired; (b) Completion of the 01iginal Services by others ; ( c) Subsequent additions to the 01iginal Services ; and/ or ( d) Other City projects. 7.5 Deliverables and Format. Contractor must provide electronic and hard copies of the Work Product, on recycled paper and copied on both sides, except for one single-sided original. 8. RECORDS Contractor must maintain complete and accurate accounting records relating to its performance in accordance with generally accepted accounting principles . The records must include detailed info1mation of Contractor 's perfo1mance, benchmarks and deliverables , which must be available to City for review and audit. The records and suppo1iing documents must be kept separate from other records and must be maintained for four years from the date of City 's final payment. 9. ASSIGNMENT Contractor shall not assign , sublease, hypothecate, or transfer this Agreement, or any interest therein , directly or indirectly, by operation of law or othe1wise , without prior written consent of City. Any attempt to do so will be null and void . Any changes related to the financial control or business nature of Contractor as a legal entity is considered an assigmnent of the Agreement and subject to City approval, which shall not be unreasonably withh eld . Control means fifty percent (50%) or more of the voting power of the business entity. 10. PUBLICITY/ SIGNS Any publicity generated by Contractor for the project under this Agreement, during the te1m of this Agreement and for one year thereafter, will reference the City 's contributions in making the C it y Proj ect/P ro gram_B_u_b_b _R_oa_d_P_ro-"-~e_c_t ------------------------- Profess ion al/Consulting Contracts /Rev. No v 16, 20/7 Page 3 of9 project possible. The words "City of Cupe1tino" will be displayed in all pieces of publicity, including flyers, press releases, posters , brochures , public service announcements, interviews and newspaper mticles. No signs may be posted, exhibited or displayed on or about City prope1ty, except signage required by law or this Contract, without prior written approval from the City. 11. INDEMNIFICATION 11.1 To the fullest extent allowed by law, and except for losses caused by the sole and active negligence or willful misconduct of City personnel, Contractor shall indemnify, defend and hold hmmless City, its City Council, boards and commissions, officers, officials, employees, agents, servants, volunteers and consultants ("Indemnitees "), through legal counsel acceptable to City, from and against any and all liability, damages, claims, actions, causes of action, demands , charges, losses, costs and expenses (including attorney fees, legal costs and expenses related to litigation and dispute resolution proceedings) of every nature, arising directly or indirectly from this Agreement or in any manner relating to any of the following: (a) Breach of contract, obligations, representations or wmTanties; (b) Negligent or willful acts or omissions comn1itted during perfo1mance of the Services; ( c) Personal injury, prope1ty damage, or economic loss resulting from the work or perfo1mance of Contractor or its subcontractors or sub-subcontractors; ( d) Unauthmized use or disclosure of City's confidential and prop1ietary Info1mation; (e) Claim of infringement or violation of a U.S. patent or copyright, trade secret, trademark, or service mark or other proprietary or intellectual prope1ty rights of any third pmty. 11.2 Contractor must pay the costs City incurs in enforcing this provision. Contractor must accept a tender of defense upon receiving notice from City of a third-party claim, in accordance with California Public Contract Code Section 9201 . At City's request, Contractor will assist City in the defense of a claim, dispute or lawsuit arising out of this Agreement. 11.3 Contractor's duties under this section are not limited to the Contract Price, workers' compensation payments, or the insurance or bond amounts required in the Agreement. Nothing in the Agreement shall be constrned to give rise to an implied right of indemnity in favor of Contractor against City or any Indemnitee. 11.4. Contractor's payments may be deducted or offset to cover any money the City lost due to a claim or counterclaim aiising out of this Agreement, a purchase order, or other transaction . 12. INSURANCE Contractor shall comply with the Insurance Requirements, attached and incorporated here as Exhibit D, and must maintain the insurance for the duration of the Agreement, or longer as required by City. City will not execute the Agreement until City approves receipt of satisfactory ce1tificates of insurance and endorsements evidencing the type, amount, class of operations covered, and the effective and expiration dates of coverage. Failure to comply with this provision may result in City, at its sole discretion and without notice, purchasing insurance for Contractor and deducting the costs from Contractor's compensation or tenninating the Agreement. C ity Project/Program_B_t_1b_b_R_oa_d_P_ro-"-je_c_t ------------------------- Professiona/lC011su/1ing Contracts !Rev. Nov 16, 20 /7 Pa ge 4 o f9 13. COMPLIANCE WITH LAWS 13.1 General Laws. Contractor shall c omply with all local , state and federal laws and regulations applicable to this Agreement. Contractor w ill promptly notify City of changes in the law or other conditions that may affect the .Project or Contractor 's ability to perfmm. Contractor is responsible for verifying the employment authorization of employees perfmming the Services , as required by the Immigration Refo1m and Control Act. 13.2 Labor Laws. Contractor shall comply with all labor laws applicable to this Agreement. If the Scope of Serv ices includes a "public works" component, Contractor is required to comply with prevailing wage laws under Labor Code Section 1720 and other labor laws. 13.3 Discrimination Laws. Contractor shall not disc1iminate on the basis of race, religious creed , color, ancestry, national origin, ethnicity, handicap , disability, marital status , pregnancy, age , sex, gender, sexual orientation, gender identity, Acquired-Immune Deficiency Syndrome (AIDS) or any other protected classification. Contractor shall comply with all anti-disc1imination laws , including Government Code Sections 12900 and 11135 , and Labor Code Sections 1735 , 1777 and 3077 .5 . Consistent with City policy prohibiting harassment and disc1imination , Contractor understands that harassment and disc1imination direct ed toward a job applicant, an employee, a City employee , or any other person, by Contractor or its employees or sub-contractors will not be tolerated . 13.4 Conflicts of Interest. Contractor shall comply with all conflict of interest laws applicabl e to this Agreement and must avoid any conflict of interest. Contractor wanants that no public official, employee, or member of a City board or commission who might have been involved in the making of this Agreement, has or will receive a direct or indirect financial interest in this Agreement, in violation of California Government Code Section 1090 et seq . Contractor may be required to file a conflict of interest form if Contractor makes certain govenunental decisions or serves in a staff capacity, as defined in Section 18700 of the California Code of Regulations. Contractor agrees to abide by the City's rnles governing gifts to public officials and employees. 13.5 Remedies. Any violation of Section 13 constitutes a mate1ial breach and may result in City suspending payments, requiring reimbursements or tenninating this Agreement. City reserves all other rights and remedies available under the law and thi s Agreement, including the right to seek indemnification under Section 11 of this Agreement. 14. PROJECT COORDINATION City Project Manager . The City assigns Jeff Tsumura. Assistant Planner ____________ a s the City 's representative for all purpo se s under this Agreement, with authority to oversee the progress and perfonnance of the Scop e of Services. City reserves th e ri ght to substitute another Project manage r at any time, and without prior notice to Contractor. City P roj ect/P ro gra m._B_u_b_b_R_oa_d_P_ro--'-~-ec_t ________________________ _ Professional/Cons ultin g Con tra cts /Re v. Nov 16, 20 17 Page 5 of 9 Contractor Project Manager. Subject to City approval, Contractor assigns Cindy Gnos. Senior Vice President as its single Representative for all purposes under this Agreement, with authority to oversee the progress and performance of the Scope of Services. Contractor's Project manager is responsible for coordinating and scheduling the Services in accordance with the Scope of Services and the Schedule of Perf01mance . Contractor must regularly update the City's Project Manager about the progress with the work or any delays , as required under the Scope of Services. City written approval is required prior to substituting a new Representative. 15. ABANDONMENT OF PROJECT City may abandon or postpone the Project or paiis therefor at any time. Contractor will be compensated for satisfactory Services pe1fo1med through the date of abandonment, and will be given reasonable time to assemble the work and close out the Services . With City 's pre-approval in w1iting, the time spent in closing out the Services will be compensated up to a maximum of ten percent (10%) of the total time expended to date in the perfo1mance of the Services. 16. TERMINATION City may te1minate this Agreement for cause or without cause at any time . Contractor will be paid for satisfactory Services rendered through the date of termination , but final payment will not be made until Contractor closes out the Services and delivers the Work Product. 17. GOVERNING LAW, VENUE AND DISPUTE RESOLUTION This Agreement is governed by the laws of the State of California . Any lawsuits filed related to this Agreement must be filed with the Superior Court for the County of Santa Clara, State of California . Contractor must comply with the claims filing requirements under the Government Code p1ior to filing a civil action in comi. If a dispute mises, Contractor must continue to provide the Services pending resolution of the dispute. If the Pa1iies elect arbitration, the arbitrator's award must be supported by law and substantial evidence and include detailed w1itten findings of law and fact. 18. ATTORNEY FEES If City initiates legal action , files a complaint or cross-complaint, or pursues arbitration, appeal , or other proceedin gs to enforce its Iights or a judgment in connection with this Agreement, the prevailing party will be entitled to reasonable attorney fees and costs . 19. THIRD PARTY BENEFICIARIES There are no intended third pa1iy beneficiaries of this Agreement. City Project/Program._B_u_b_b_R_oa_d_P_ro..::.~e_c_t ------------------------- Pr ofess iona//Co ns 11/t i11g Con tra cts /Rev. Nov I 6, 20 17 Pa ge 6 of9 20. WAIVER Neither acceptance of the Services nor payment thereof shall constitute a waiver of any contract provision . City 's waiver of a breach shall not constitute waiver of another provision or breach. 21. ENTIRE AGREEMENT This Agreement represents the full and complete understanding of every kind or nature between the Pmiies , and supersedes any other agreement(s) and understanding(s), either oral or written, . between the Pmiies . Any modification of this Agreement will be effective only if in writing and signed by each Pmiy 's authorized representative . No verbal agreement or implied covenant will be valid to amend or ab1idge this Agreement. If there is any inconsistency between the main Agreement and the attachments or exhibits thereto , the text of the main Agreement shall prevail. 22. INSERTED PROVISIONS Each provision and clause required by law for this Agreement is deemed to be included and will be infened herein. Either party may request an amendment to cure mistaken inse11ions or omissions of required provisions . The Pmiies will collaborate to implement this Section, as appropriate. 23. HEADINGS The headings in this Agreement are for convenience only, are not a part of the Agreement and in no way affect, limit or amplify the tenns or provisions of this Agreement. 24. SEVERABILITY/PARTIAL INVALIDITY If any term or provision of this Agreement, or their application to a particular situation, is found by the court to be void, invalid, illegal or unenforceable, such term or provision shall remain in force and effect to the extent allowed by such rnling. All other te1ms and provisions of this Agreement or their application to specific situations shall remain in full force and effect. The Pa11ies agree to work in good faith to amend this Agreement to cany out its intent. 25. SURVIVAL All provisions which by their nature must continue after the Agreement expires or is terminated , including the Indemnification, Ownership of Materials/Work Product, Records , Governing Law and Attorney Fees, shall survive the Agreement and remain in full force and effect. City Project/Program_B_t_1b_b_R_oa_d_P_ro~~e_c_t ------------------------- Professional/Consulting Con tracts /Rev. Nov 16, 2017 Pa ge 7 of9 26. NOTICES All notices, requests and approvals must be sent in writing to the persons below, which will be considered effective on the date of personal delivery or the date confirmed b y a reputable overnight delivery service, on the fifth calendar day after deposit in the United States Mail, postage prepaid, registered or ce11ified, or the next business day following electronic submission: To City of Cupe11ino 10300 ToITe Ave. Cupe11ino CA 95014 Attention: JeffTsumura Email: Jeffre yMT @Cupertino.org 27. VALIDITY OF CONTRACT To Contractor: ------------- Raney Planning & Mana gement, Inc. 150 I Sports Drive , Suite A Sacramento , CA95834 Attention: Cindy Gno s -------------- Email: info @raneymanagement.com This Agreement is valid and enforceable only if (a) it complies with the purchasing and contract provisions of Cupe11ino Municipal Code Chapters 3.22 and 3.23, as amended from time to time, (b) is signed by the City Manager or an authorized designee, and (c) is approved for fmm by the City Attorney's Office. 28. EXECUTION The person executing this Agreement on behalf of Contractor represents and waITants that Contractor has full right, power, and authority to enter into and carry out all actions contemplated by this Agreement and that he or she is authorized to execute this Agreement, which constitutes a legally binding obligation of Contractor. This Agreement may be executed in counterparts, each one of which is deemed an original and all of which, taken together, constitute a single binding instrument. City Project/P ro g ram_B_u_b_b_R_oa_d_P_ro-=-~e_c_t ------------------------- Professional/Co nsulting Co ntra cts /Rev. Nov 16, 20 17 Page 8 of9 IN WITNESS WHEREOF, the parties have caused the Agreement to be executed. CONTRACTOR Raney Planning & Management, Inc :~S:lt~ Title ~. \J l(:g P(..e~cd....Q~d Date \-lO ·t~ Tax ID. No.: q.4,r'3'Y£ Cf;}.:)., 7 Cupertino City Attorney ATTEST: ~ ~ Id GRAESCHMIDT City Clerk J.. -S:--1 ~ CITY OF CUPERTINO A Municipal Corporation Name A/r/Zl/ Sf/R/ffy5J71 t/ll Title ,#!Er · e/TYJ/6£-- Date OJ/Jo/;z ,, City Project/Program'--B_ub_b_R_oa_d _Pr-"-oje_ct ___________________ _ Professional/Con sulting Contracts /Rev. No v 16, 201 7 Page 9 of9 Exhibit A PRO PO SA L TO PREPARE AN INITIAL STUD Y I M I T I GATED NEGATIVE DEC L A R ATION Bubb Road Project Cupertino, CA December 11, 2017 Submitted to: Jeffrey Tsumura, Assistant Planner City of Cupertino 10300 Torre Avenue Cupertino, CA 95014 Office: (408) 777-3319 Email: jeffreyMT@ cupertino.org Submitted by: Raney Planning & Management, Inc . 1501 Sports Drive , Suite A Sacramento, CA 95834 Office: (916) 372-6100 Fax: (916) 419-6108 Email: info @raneymanagement.com Contacts: Cindy Gnos , AICP Senior Vice President Nick Pappani Vice President RANEY TABLE OF CONTENTS l. Project Understanding I I. Tech nical Scope of Services 3 Ill. Schedule 7 IV . Cost Proposa l 8 Append ix A : Res um es '4 RANEY I. Project Understanding Raney, a division of Raney Planning & Management, Inc ., has tailored the following proposal and scope of services to prepare an Initial Study for the Bubb Road project (proposed project) in the City of Cupe1tino , CA. PROJECT OVERVIEW Project Loc:ation /Description The proposed project is located at 11226 Bubb Road , on the south side of Krzich Place, in the southern po1tion of the City of Cupe1tino (APN 362-06-036). The project site is zoned for Single- Family Residential with a minimum lot si z e of 7,500 square feet (Rl-7 .5), with a designated land use of low-density residential in the City of Cupertino General Plan. The project site contains a single-family residence, an in-ground pool, and a detached pool house . Sunounding land uses include single family residential to the north, east, south, and west. The project applicant is seeking ministerial approval to subdivide the single 33 ,060 square-foot lot into three lots (two 9 ,746 square-foot lots and one 11,915 square-foot lot), and to demolish the existing strnctures. APPROACH Raney proposes to prepare an Initial Study to analyze the potential environmental effects associated with the implementation of the proposed project. The Initial Study will be prepared using the checklist contained in Appendix G of the CEQA Guidelines and the standard City of Cupe1tino format. Raney anticipates that the key environmental issue area that may require a more in-depth discussion in the Initial Study will be Haz ards and Hazardous Materials . Raney understands that the applicant has provided updated Phase I and Phase II Environmental Site Assessments (ESA) prepared by Enviro Assessment, PC in November 2017 for the project site . Raney anticipates that the Updated Phase II ESA will contain updated testing levels and address the comments from David J. Power 's peer review . Raney assumes that all of the impacts due to the proposed project will be reduced to a less-than- significant level with the implementation of appropriate and practical mitigation measures and therefore, the appropriate CEQA document will be a Mitigated Negative Declaration. Raney will work closely with City staff in the preparation of the Initial Study and dete1mination of appropriate findings and mitigation measures. The Initial Study will provide a discussion of the impacts related to implementation of the proposed project. It should be noted that Raney anticipates that the City of Cupertino will handle any required tribal consultation pursuant to AB 52. Should the City need assistance, Raney is available to help , upon r equest, and would propo se to amend the scop e of work, schedule , and budget. f-RANEY Raney firmly believes that the level of coordination between the City and the local citizens is directly propo1iional to the success of the project. Raney intends to work closely with the City of Cupe1iino throughout the development and processing of the Initial Study. Raney will remain objective and rely on the City to make the ultimate dete1mination on the conclusions and mitigation measures. The expectation of Raney is that we will serve as enviromnental consultants to the City, and will make ourselves available to assist the City in any way necessary to facilitate the process. Information Needs Raney requests the following info1mation in order to accurately assess the potential enviromnental impacts of the proposed project: • CmTent set of project plans; and • Estimate for soil off-haul associated with the Phase II remediation goals. 2 RANEY II. Technical Scope of Services ----The following scope of services has been developed to prepare an Initial Study/Mitigated Negative Declaration (IS /MND) for the Bubb Road project. This scope of services identifies each task in the preparation of the necessary documents and includes an objective, approach, and work product associated with each task. TASK l PROJECT INITIATION Objective The objective of this task is to coordinate with City staff and the project team to review the existing project infonnation, attend a kick-off meeting to discuss the process, if requested, and to refine the scope of work as necessary. Approach Senior Vice President Cindy Gnos , AICP, will serve as the Project Director and will be responsible for overseeing preparation of the environmental document. Vice President Nick Pappani will serve as the Project Manager for the preparation of the Initial Study. Mr. Pappani will patiicipate in a kick-off meeting with City staff and the project team, if requested. Raney will coordinate with staff to review the ex isting documentation for the project , perform a site visit, and identify the project issues and confirm assumptions . In addition, any necessary refinements to the Raney scope of work will be discussed . Raney will submit the final scope, with any necessary revisions, to the City for approval. TASK 1 PRODUCTS • Receipt of project information . • Pa1iicipate in a kick-off meeting, if requested, and site visit. • Refine scope as necessary and provide final scope to City for approval. TASK 2 PREPARE ADMINISTRATIVE DRAFT INITIAL STUDY Objecti1 •e The objective of this task is to prepare an Administrative Draft version of the Initial Study for review by City staff. . lppmach Raney will prepare an Administrative Draft Initial Study for review by the City. The analysis in the Initial Study will address the potential enviromnental impacts as a result of the proposed project. The Initial Study will provide an introduction, project description, g raphics , illustrations , and enviromnental checklist and discussion. Raney will utili ze the standard environmental checklist fo1mat , based upon Appendix G of the CEQA guidelines. 3 RANEY Raney anticipates that the key issue area , which may require a more in-depth discussion in the Initial Study, will be Hazards and Hazardous Mate1ials. The following summarizes how Raney proposes to analyze the key issue area , relying on existing technical inf01mation to be provided by the City and/or the applicant team as well as on internal analyses conducted by Raney staff. Ha z ards and Hazardous Mate1ials The Hazards and Hazardous Materials section will address the potential for any existing hazards or hazardous materials within the project area. In paiticular, this section will address any existing hazards (e.g. pesticides) associated with the site's former use as an almond orchard. Raney will rely on the updated Phase I and Phase II Environmental Site Assessments, prepared by Enviro Assessment P .C. on November 17, 2017 . Raney anticipates that the updated Phase II Environmental Site Assessment will address the comments received during David J. Powers ' Peer Review of the report. Raney will fmther internally review the repo1is to ensure that all CEQA issues have been adequately and accurately addressed and will incorporate the results of the analyses into the Hazards and Hazardous Materials section of the Initial Study. Remaining Issue Areas The remaining issue areas of the Initial Study will be based upon information provided by the applicant and the City as well as pe1tinent City documents, including but not limited to the Cupertino General Plan, General Plan EIR, and any other pe1tinent information prepared for the project site and smrnunding area. TASK 2 PRODUCTS • One (1) electronic copy, in PDF format, of the Administrative Draft Initial Study to the City of Cupe1iino . TASK 3 REVISE ADMINISTRATIVE DRAFT AND PREPARE PUBLIC REVIEW INITIAL STUDY FOR CITY RELEASE TO THE PUBLIC Ohjecrii·e The objective of this task is to edit the Administrative Draft Initial Study based on the comments received from City staff and to prepare and submit the Public Review Initial Study to the City for distribution . Approach Raney will revise the Administrative Draft Initial Study based on comments provided by the City. Raney will incorporate comments and submit a final version of the document to the City of Cupertino . Raney will assist the City in the distribution of the Initial Study , including preparing the Notice of Intent to Adopt a Mitigated Negative Declaration. Raney assumes the City will publish the notice in the paper, post the Tnitial Study on-line, and provide a copy of the notice and Initial Study to the County Clerk. Given that the project is not of statewide, regional , or areawide significance, pursuant to CEQA Guidelines Section 15206, Raney has assumed that the IS /MND 4 RANEY would not be submitted to the State Clearinghouse for state agency review, and the public document review period will be twenty (20) days . TASK3 PRODUCTS • One (1) unbound original copy of the final version of the Initial Study and one (1) electronic file on CD in PDF f01mat to the City of Cupe1iino. • Preparation of the Notice of Intent to Adopt a Mitigated Negative Declaration. • Preparation of Notice of Dete1mination (if approved). TASK4 PREPARE MITIGATION MONITORING AND REPORTING PROGRAM (MMRP) Objec:ti1'e The objective of this task is to prepare a Mitigation Monitoring and Rep01iing Program (MMRP) for the City of Cupe1iino. Approach Raney will prepare an administrative review copy of the MMRP, using the environmental analysis and the City 's standard format. The administrative review MMRP will incorporate existing monitoring mechanisms that are in place in order to assist the City of Cupertino in meeting the intent of CEQA. The MMRP will be in table fo1mat, and will specify mitigation measures, standards of success, paiiies responsible for implementing and monitoring, and timing. Raney will revise the administrative review MMRP based on City comments and prepare a final MMRP to be submitted to the City of Cupe1iino with the Public Review Initial Study. TASK 4 PRODUCTS • One (1) electronic file in Word and PDF format of the MMRP to the City of Cupertino with the Public Review Initial Study. TASKS RESPONSE TO COMMENTS Ohjecti, ·e The objective of this task is to provide a written response to any comments received during the public review period of the Initial Study, if necessary. Approach Raney will provide written responses to c01mnents received during the Initial Study public review period . Raney will coordinate with the City of Cupe1iino in the preparation of the written responses to c01mnents received , and produce an e1rnta sheet should any comments necessitate changes to the Initial Study text. Although CEQA does not require written responses to c01mnents on an /(__RANEY 5 Initial Study, Raney suggests the written responses be included in the staff report to ensure the decision-makers have adequate inf01mation on which to base their decision . TASK 5 PRODUCTS • Responses to comments received from public review of the Initial Study. • Errata sheet detailing any changes to the Initial Study text based on the public comments received, as necessary. TASK6 PROJECT MANAGEMENT Objective The objective of this task is to ensure close coordination with the City of Cupe1tino and the project team and throughout the processing of the environmental document. Approach Senior Vice President Cindy Gnos, AICP, will serve as the Project Director and will be responsible for overseeing preparation of the environmental document and coordinating with City staff. Vice President Nick Pappani will serve as the Project Manager and will be responsible for managing the day-to-day preparation of the environmental document, coordinating with City staff and the project team, and responding to inquiries on the environmental document and the process . R a ney will assist City staff in an y way necessary throughout the environmental review process and anticipates regular phone and e-mail communication with City staff and the project team . Raney has assumed attendance at public hearings and in-person meetings would not be necessary; however, attendance at in-person meetings could easily be accommodated upon request and would be billed on a time-and-materials basis following Raney 's standard billing rates. TASK 6 PRODUCTS • Coordination and assistance throughout the environmental review process . • Regular phone and e-mail communication with City staff and the project team. 6 RANEY Exhibit B The following tentative schedule is based on experience preparing environmental documents for similar projects. The schedule could be lengthened or sho11ened, depending on the needs of the City of Cupertino . Factors that could lengthen or sho11en the schedule include dates of receipt of project information (including info1mation from the applicant), length of document reviews and unanticipated issues arising from City staff, project team, or public review of the environmental document. ... --I 11::.i ill II Hll ffi!:IJjJ]flli'J'iTfu r ,n m1 !t.ul!lli'9 Milestones & Deliverables Timing Anticipated Date Notice to Proceed (NTP) TBD -December 18, 2017 Project Initiation Meeting Week ofNTP Week of December 18, 2017 Administrative Draft Initial Study to the City Four (4) weeks from January 15, 2018 of Cupertino for review NTP Receipt of City comments on Administrative Two (2) weeks January 29 , 2018 Draft Initial Study Public Review Initial Study to the City of One and a half (1.5) Febrnary 8, 2018 Cupe11ino weeks Public Review Pe1iod (20 days, per CEQA Twenty (20) days Febrnary 9, 2018 to Guidelines Section 15 073) March 1, 2018 Provide Responses to public comments, if Three (3) days March 6, 2018 applicable Director approval of IS /MND Within one (1) week March 13, 2018 7 RANEY Exhibit C The cost for completion of the Bubb Road Initial Study is anticipated not to exceed $9,100 . These costs are based on the estimates of time for each task provided in the spreadsheet below. Costs for the Initial Study preparation will be billed on a not-to-exceed basis, following Raney standard billing rates also included in the spreadsheet below. The following assumptions were used in the calculations . • Attendance at meetings and hearings is not included in the scope of work, but could be easily be accommodated and would be billed on a time-and-materials basis, as directed . • Raney costs are based on the assumption that the existing data and info1mation for the City of Cupe11ino and the proposed project site is accurate and cmTent and will be available for the preparation of the proposed environmental documents. • Should tribal consultation be required under AB 52, Raney assumes the City will handle this consultation. However, Raney will be available to assist the city as needed, upon request. Raney would propose to amend the scope of work, schedule, and budget accordingly. • Raney will provide to the City of Cupe11ino and the project team the number of copies of the documents as indicated in the technical scope of services . The cost estimate for copying/printing is just an estimate and will be billed to the applicant at actual cost. • Raney assumes that once a Notice to Proceed is issued, the preparation of the environmental documents would be a continuous process without excessive delays. Raney would propose to renegotiate the contract with respect to schedule and cost should substantial delays occur in the processing of the proposed project. • Factors that would increase the scope of work and estimated costs outlined in the proposal include: attendance at additional meetings or public hearings ; printing of additional copies of reports; analysis of additional issues above those discussed in this proposal or a more detailed level of analysis than described in this proposal; changes in the project requiring reanalysis or rewriting of rep011 sections; collection of data required for the environmental documents beyond that described in this proposal; and excessive c01mnents on the enviromnental documents . Raney would propose to renegotiate these items , if required , or charge on a time-and-materials basis . 8 RANEY r:IUf:l:11:UMIJl l~lll,.iJL,~ l!l!Elj"I :I.. "t 11 i', r! \11.:1 I.. I.. 0 Q.) ~ +-' OJ (/) () Cl! Q.) Cl! ~ C +-' f-Cl! Cl! 0 ~ () I.. Q.) +-' 0 0.. +-' (/) () () Q.) (/) +-' Q.) <( (/) 'o 'o 0 I.. I.. 0 0.. 0.. Task 1 Project Initiation 6 $ 900 Task 2 Prepare Administrati\€ Draft Initial Study 2 6 30 $ 4,240 Task 3 Revise AD IS/MND and Prepare Public Review IS/MND 2 4 $ 700 Task 4 Prepare MMRP 1 2 $ 350 Task 5 Response to comments, if needed 1 1 2 $ 520 Task 6 Project Manaqement and Meetinq Attendance 2 10 $ 1,840 Total Hours 5 26 38 Hourly Rate $ 170 $ 150 $ 100 Total Labor $ 850 $ 3,900 $ 3,800 $ 8,550 Sub-Consultants & Expenses Copying/Printing/Tra\€1/Postage/Etc. * $ 500 10% administrati\€ fee $ 50 Total Expenses $ 550 Total Budget $ 9,100 *Estimate only; w/1 be billed at cost. 9 R-ANEY ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDD/YYYY) ~ 1/10/2018 THIS CERTIFICATE IS ISSUED AS A MATIER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ~~~~~cT Paraaon Insurance Services Paragon Insurance Services ;.~~'t\'n "··"· 916-353-1023 J iAi~ Nol : 916-353-1370 301 Natoma St #104 Folsom CA 95630 !oMl~~ss: commercial@oaraqoninsservices.com INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Gemini Insurance Company 10833 INSURED RANEY-1 INSURER e : Liberty Mutual Insurance Co. 20343 Raney Planning & Management, Inc. INSURER c : Ohio Security Insurance Co 1501 Sports Drive Sacramento CA 95834 INSURER D : INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 890312265 REVISION NUMBER: TH IS IS TO C ERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN , THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS , EXCLUSIONS AND CONDITIONS OF SUCH POLICIES . LI MITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLIC Y EFF POLIC Y EXP LIMITS LTR TYPE OF INSURANCE ····" "'"'" POLIC Y NUMBER /MM I DD /YYYYl /MMIDD/YYYYl B X COMMERCIAL GENERAL LIABILITY BKS57775071 5/1/2017 5/1/2018 EACH OCCURRENCE $2,000 ,000 f--0 CLAIMS-MADE 0 OCCUR DAMAGE TO RENTED PREMISES /Ea occurrencel $100,000 MED EXP (Any one pe rso n) $10,000 r-- PERSONAL & ADV INJURY $2,000,00 0 - GEN'L AGGREGATE LIMIT APP LI ES PER: GENERAL AGGREGATE $4,000,000 =i 0PRO-OLoc PRODUCTS · COMP/OP AGG $2,000 ,000 POLICY JECT OTHER : Deductible $NI L C AUTOMOBILE LIABILITY BAS57775071 5/1/2017 5/1/2 018 COMBINED SINGLE LIMIT $1000000 t Ea accident\ - X ANY AUTO BODILY INJUR Y (Per person) $ --ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ r---NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS /Per accident! $ r--- Deduct ible $NIL UMBRELLA LIAB HOCCUR EACH OCCURR ENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION XWS5777507 1 5/1/2017 5/1/2018 X I ~ffTuTE I I OTH-ER AND EMPLOYERS' LIABILITY Y/N ANY PROPR IE TOR/PARTNER/EXECUTIVE [I] N/A E.L. EACH ACCIDENT $1,000,000 OFFICER /M EMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE · EA EMPLOYEE $1 ,000 ,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEA SE · POLICY LIMIT $1 ,000,000 A Pro/essional Liabilily VNP L002454 7/28/20 17 5/1/2018 Ea ch Claim 2,000,000 Aggregate 2,000,000 Deductible per clai m 5,000 DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project Name: Bubb Road IS/MND City of Cuperti n o , its City Council , officers, officials , employees , agents , servants and volu nteers are to be covered as additional in s ureds with respect to liability arising out of work or operations performed by or on behalf of Contractor including materials, parts or equipment furnished in connection with such work or operations . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH T HE POLICY PROVISIONS. City of Cupertino 10300 Torre Avenue AUTHORIZED REPRESENTATIVE Cupertino CA 95014 ~d??£~k~, I © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD COMMERCIAL AUTO CA88100113 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE ENHANCEMENT ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. COVERAGE INDEX SUBJECT ADDITIONAL INSURED BY CONTRACT , AGREEMENT OR PERMIT ACCIDENTAL AIRBAG DEPLOYMENT AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS AMENDED FELLOW EMPLOYEE EXCLUSION AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE BROAD FORM INSURED BODILY INJURY REDEFINED EMPLOYEES AS INSUREDS (including employee hired auto) EXTENDED CANCELLATION CONDITION EXTRA EXPENSE-BROADENED COVERAGE GLASS REPAIR -WAIVER OF DEDUCTIBLE HIRED AUTO PHYSICAL DAMAGE (including employee hired auto and loss of use) HIRED AUTO COVERAGE TERRITORY LOAN / LEASE GAP PARKED AUTO COLLISION COVERAGE (WAIVER OF DEDUCTIBLE) PERSONAL EFFECTS COVERAGE PHYSICAL DAMAGE -ADDITIONAL TRANSPORTATION EXPENSE COVERAGE RENTAL REIMBURSEMENT SUPPLEMENTARY PAYMENTS TOWING AND LABOR TWO OR MORE DEDUCTIBLES UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US SECTION II -LIABILITY COVERAGE is amended as follows: 1. BROAD FORM INSURED PROVISION NUMBER 3 12 19 5 13 1 22 2 23 10 15 6 20 14 16 11 8 9 4 7 17 18 20 SECTION II -LIABILITY COVERAGE, paragraph A.1 . -WHO IS AN INSURED is amended to include the following as an insured: CA88100113 d. Any legally incorporated entity of which you own more than 50 percent of the voting stock during the policy period . However, "insured " does not include any organization that: (1) Is a partnership or joint venture; or (2) Is an insured under any other automob ile policy; or (3) Has exhausted its Limit of Insurance under any other automobile policy. Paragraph d. (2) of this provision does not apply to a policy written to apply specifically in excess of this policy . e. Any organization you newly acquire or form , other than a partnership or joint venture , of which you own more than 50 percent of the voting stock. This automatic coverage is afforded only for 180 days from the date of acquisition or formation . However, coverage under this provision does not apply: (1) If there is similar insurance or a self-insured retention plan available to that organization; © 20 13 Lib e rt y Mutual In surance Includes copyrig hted materia l of In suran ce Services Office, In c., wi th it s permission. Page 1 of 7 35432931 J 57775071 I 17-18 Master Cerci f icate I Kendra Anderson J 5/3/2017 1:50:18 PM (COT) I Page 2 of 17 (2) If the Limits of Insurance of any other insurance policy have been exhausted; or (3) To "bodily injury" or "property damage" that occurred before you acquired or formed the organization . 2. EMPLOYEES AS INSUREDS SECTION II -LIABILITY COVERAGE, paragraph A.1 . -WHO IS AN INSURED is amended to include the following as an insured : f. Any "employee" of yours while using a covered "auto " you do not own, hire or borrow, but only for acts within the scope of their employment by you. Insurance provided by this endorsement is excess over any other insurance available to any "employee". g . An "employee" of yours while operating an "auto" hired or borrowed under a written contract or agreement in that "employee's" name , with your permission , while performing duties related to the conduct of your business and within the scope of their employment. Insurance provided by this endorsement is excess over any other insurance available to the "employee ". 3. ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT SECTION II -LIABILITY COVERAGE , paragraph A.1. -WHO IS AN INSURED is amended to include the following as an insured : h . Any person or organization with respect to the operation, maintenance or use of a covered "auto", provided that you and such person or organization have agreed in a written contract, agreement , or permit issued to you by governmental or public authority, to add such person , or organization, or governmental or public authority to this policy as an "insured". However, such person or organization is an "insured": (1) Only with respect to the operation , maintenance or use of a covered "auto"; (2) Only for "bodily injury" or "property damage" caused by an "accident" which takes place after you executed the written contract or agreement, or the permit has been issued to you; and (3) Only for the duration of that contract, agreement or permit 4. SUPPLEMENTARY PAYMENTS SECTION II -LIABILITY COVERAGE, Coverage Extensions, 2.a. Supplementary Payments , paragraphs (2) and (4) are replaced by the following: (2) Up to $3 ,000 for cost of bail bonds (including bonds for related traffic violations) required because of an "accident" we cover. We do not have to furnish these bonds . (4) All reasonable expenses incurred by the insured at our request, including actual loss of earnings up to $500 a day because of time off from work. 5. AMENDED FELLOW EMPLOYEE EXCLUSION In those jurisdictions where, by law, fellow employees are not entitled to the protection afforded to the employer by the workers compensation exclusivity rule , or similar protection, the following provision is added: SECTION II -LIABILITY, exclusion B .5. FELLOW EMPLOYEE does not apply if the "bodily injury" results from the use of a covered "auto" you own or hire. SECTION Ill -PHYSICAL DAMAGE COVERAGE is amended as follows: 6. HIRED AUTO PHYSICAL DAMAGE CA 88 10 01 13 Paragraph A.4 . Coverage Extensions of SECTION Ill -PHYSICAL DAMAGE COVERAGE, is amended by adding the following : If hired "autos" are covered "autos" for Liability Coverage, and if Comprehensive, Specified Causes of Loss or Collision coverage are provided under the Business Auto Coverage Form for any "auto " you own , then the Physical Damage coverages provided are extended to "autos": a. You hire, rent or borrow; or © 2013 Liberty Mutual Insurance In cludes copyrighted material of Insurance Services Office, Inc ., with its pe rmi ssion. Page 2 of 7 3543293 1 j 5777507 1 I 1 7-18 Master Certif i cate I Kendra Anderson I 5/3/20 1 7 1:50 :1 8 PM (CDT) I Page 3 o f 1 7 b. Your "employee " hires or rents under a written contract or agreement in that "employee's" name, but only if the damage occurs while the vehicle is being used in the conduct of your business, subject to the following limit and deductible: A. The most we will pay for "loss" in any one "accident" or "loss" is the smallest of: (1) $50,000; or (2) The actual cash value of the damaged or stolen property as of the time of the "loss"; or (3) The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality, minus a deductible . B . The deductible will be equal to the largest deductible applicable to any owned "auto" for that coverage. C. Subject to the limit, deductible and excess provisions described in this provision, we will provide coverage equal to the broadest coverage applicable to any covered "auto " you own. D. Subject to a maximum of $1 ,000 per "accident", we will also cover the actual loss of use of the hired "auto" if it results from an "accident", you are legally liable and the lessor incurs an actual financial loss. E. This coverage extension does not apply to : (1) Any "auto " that is hired, rented or borrowed with a driver; or (2) Any "auto " that is hired, rented or borrowed from your "employee". For the purposes of this provision , SECTION V -DEFINITIONS is amended by adding the following : "Total loss " means a "loss" in which the cost of repairs plus the salvage value exceeds the actual cash value . 7. TOWING AND LABOR SECTION Ill -PHYSICAL DAMAGE COVERAGE, paragraph A.2 . Towing , is amended by the addition of the following : We will pay towing and labor costs incurred, up to the limits shown below, each time a covered "auto " classified and rated as a private passenger type , "light truck" or "medium truck" is disabled: a . For private passenger type vehicles , we will pay up to $50 per disablement. b. For "light trucks", we will pay up to $50 per disablement. "Light trucks " are trucks that have a gross vehicle weight (GVW) of 10,000 pounds or less. c . For "medium trucks " , we will pay up to $150 per disablement. "Medium trucks " are trucks that have a gross vehicle weight (GVW) of 10 ,001 -20 ,000 pounds . However, the labor must be performed at the place of disablement. 8. PHYSICAL DAMAGE· ADDITIONAL TRANSPORTATION EXPENSE COVERAGE CA 88 10 01 13 Paragraph A.4 .a., Coverage Extension of SECTION Ill -PHYSICAL DAMAGE COVERAGE , is amended to provide a limit of $50 per day and a maximum limit of $1 ,500 © 2013 Lib e rty Mutual In su ran ce Includes copyrighted material of Insurance Services Office , Inc ., with its permission . Page 3 of 7 35432931 I 577 7507 1 I 17-18 Master Certificate I Kendra Ar1derson I 5/3/2017 1:50:18 PM (COT) I Page 4 o f 17 9. RENTAL REIMBURSEMENT SECTION Ill -PHYSICAL DAMAGE COVERAGE, A. COVERAGE, is amended by adding the following : a. We will pay up to $75 per day for rental reimbursement expenses incurred by you for the rental of an "auto" because of "accident" or "loss", to an "auto" for which we also pay a "loss" under Comprehensive, Specified Causes of Loss or Collision Coverages . We will pay only for those expenses incurred after the first 24 hours following the "accident" or "loss" to the covered "auto ." b. Rental Reimbursement will be based on the rental of a comparable vehicle , which in many cases may be substantially less than $75 per day, and will only be allowed for the period of time it should take to repair or replace the vehicle with reasonable speed and similar quality, up to a maximum of 30 days. c. We will also pay up to $500 for reasonable and necessary expenses incurred by you to remove and replace your tools and equipment from the covered "auto". d. This coverage does not apply unless you have a business necessity that other "autos " available for your use and operation cannot fill. e. If "loss" results from the total theft of a covered "auto" of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided under Paragraph 4. Coverage Extension . f. No deductible applies to this coverage . For the purposes of this endorsement provision, materials and equipment do not include "personal effects" as defined in provision 11 . 10. EXTRA EXPENSE -BROADENED COVERAGE Under SECTION Ill -PHYSICAL DAMAGE COVERAGE, A. COVERAGE, we will pay for the expense of returning a stolen covered "auto" to you. The maximum amount we will pay is $1,000. 11. PERSONAL EFFECTS COVERAGE A . SECTION Ill -PHYSICAL DAMAGE COVERAGE, A. COVERAGE , is amended by adding the following: If you have purchased Comprehensive Coverage on this policy for an "auto" you own and that "auto " is stolen, we will pay, without application of a deductible, up to $600 for "personal effects" stolen with the "auto." The insurance provided under this provision is excess over any other collectible insurance. B. SECTION V -DEFINITIONS is amended by adding the following : For the purposes of this provision, "personal effects " mean tangible property that is worn or carried by an insured." "Personal effects " does not include tools , equipment, jewelry, money or securities . 12. ACCIDENTAL AIRBAG DEPLOYMENT SECTION Ill -PHYSICAL DAMAGE COVERAGE , B. EXCLUSIONS is amended by adding the following : If you have purchased Comprehensive or Collision Coverage under this policy, the exclusion for "loss " relating to mechanical breakdown does not apply to the accidental discharge of an airbag . Any insurance we provide shall be excess over any other collectible insurance or reimbursement by manufacturer's warranty. However, we agree to pay any deductible applicable to the other coverage or warranty. 13. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE CA 88 10 0113 SECTION Ill -PHYSICAL DAMAGE COVERAGE , B . EXCLUSIONS , exception paragraph a . to exclusions 4.c. and 4.d . is deleted and replaced with the following : © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc ., with its permission . Page 4 of 7 3543293 1 I 5 777507 1 j 1 7-18 Master Certifi cate I Kendra Anderson I 5 /3 /20 1 7 1:50 :18 PM (CDT ) I Page 5 of 1 7 Exclus ion 4.c. and 4.d. do not apply to: a. Electronic equipment that receives or transmits audio , visual or data signals, whether or not designed solely for the reproduction of sound , if the equipment is permanently installed in the covered "auto " at the time of the "loss " and such equipment is designed to be solely operated by use of the power from the "auto 's" electrical system, in or upon the covered "auto" and physical damage coverages are provided for the covered "auto "; or If the "loss " occurs solely to audio , visual or data electronic equipment or accessories used with this equipment , then our obligation to pay for, repair, return or replace damaged or stolen property will be reduced by a $100 deductible. 14. LOAN/ LEASE GAP COVERAGE CA 88 10 0113 A. Paragraph C ., LIMIT OF INSURANCE of SECTION Ill -PHYSICAL DAMAGE COVERAGE is amended by adding the following: The most we will pay for a "total loss " to a covered "auto" owned by or leased to you in any one "accident" is the greater of the : 1. Balance due under the terms of the loan or lease to which the damaged covered "auto" is subject at the time of the "loss " less the amount of: a. Overdue payments and financial penalties associated w ith those payments as of the date of the "loss ", b. Financial penalties imposed under a lease due to high mileage , excessive use or abnormal wear and tear, c . Costs for extended warranties, Credit Life Insurance , Health , Accident or Disability Insurance purchased with the loan or lease , d . Transfer or rollover balances from previous loans or leases, e . Final payment due under a "Balloon Loan ", f. The dollar amount of any unrepaired damage which occurred prior to the "total loss " of a covered "auto ", g. Security deposits not refunded by a lessor, h . All refunds payable or paid to you as a result of the early termination of a lease agreement or as a result of the early termination of any warranty or extended service agreement on a covered "auto ", i. Any amount representing ta xes , j. Loan or lease terminat ion fees; or 2. The actual cash value of the damage or stolen property as of the time of the "loss ". An adjustment for depreciation and physical condition will be made in determining the actual cash value at the time of the "loss". This adjustment is not applicable in Te xas . B. ADDITIONAL CONDITIONS This coverage applies only to the origina l loan for which the covered "auto " that incurred the loss serves as collateral, or lease written on the covered "auto " that incurred the loss . C. SECTION V -DEFINTIONS is changed by adding the following : As used in this endorsement provision , the following definitions apply : "Total loss " means a "loss " in which the cost of repairs plus the salvage value exceeds the actual cash value . A "balloon loan " is one with periodic payments that are insufficient to repay the balance over the term of the loan , thereby requiring a large final payment. © 201 3 Liberty Mutu a l Insurance Inclu des copy righted materi a l of Insuran ce Serv ices Office , In c., with its pe rmis sio n . Page 5 of 7 3543293 1 I 5777507 1 I 17-18 Mascer Certificate I Kendra Anderson I 5/3/201 7 1:50 :1 8 PM (CDT) I Page 6 of 17 15. GLASS REPAIR -WAIVER OF DEDUCTIBLE Paragraph D. Deductible of SECTION Ill -PHYSICAL DAMAGE COVERAGE is amended by the addition of the following: No deductible applies to glass damage if the glass is repaired rather than replaced . 16. PARKED AUTO COLLISION COVERAGE (WAIVER OF DEDUCTIBLE) Paragraph D. Deductible of SECTION Ill -PHYSICAL DAMAGE COVERAGE is amended by the addition of the following : The deductible does not apply to "loss" caused by collision to such covered "auto" of the private passenger type or light weight truck with a gross vehicle weight of 10,000 lbs . or less as defined by the manufacturer as maximum loaded weight the "auto " is designed to carry while it is : a. In the charge of an "in sured "; b. Legally parked; and c. Unoccupied . The "loss" must be reported to the police authorities within 24 hours of known damage. The total amount of the damage to the covered "auto" must exceed the deductible shown in the Declarations . This provision does not apply to any "loss" if the covered "auto" is in the charge of any person or organization engaged in the automobile business. 17. TWO OR MORE DEDUCTIBLES Under SECTION Ill PHYSICAL DAMAGE COVERAGE , if two or more company policies or coverage forms apply to the same accident , the following applies to paragraph D. Deductible : a. If the applicable Business Auto deductible is the smaller (or smallest) deductible it will be waived ; or b. If the applicable Business Auto deductible is not the smaller (or smallest) deductible it will be reduced by the amount of the smaller (or smallest) deductible; or c. If the loss involves two or more Business Auto coverage forms or policies the smaller (or smallest) deductible will be waived. For the purpose of this endorsement company means any company that is part of the Liberty Mutual Group . SECTION IV -BUSINESS AUTO CONDITIONS is amended as follows: 18. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS SECTION IV-BUSINESS AUTO CONDITIONS, Paragraph B.2. is amended by adding the following : If you unintentionally fail to disclose any hazards, exposures or material facts existing as of the inception date or renewal date of the Business Auto Coverage Form, the coverage afforded by this policy will not be prejudiced . However, you must report the undisclosed hazard of exposure as soon as practicable after its discovery , and we have the right to collect additional premium for any such hazard or exposure. 19. AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT, OR LOSS CA 88 10 01 13 SECTION IV -BUSINESS AUTO CONDITIONS, paragraph A.2.a. is replaced in its entirety by the following: a. In the event of "accident", claim , "suit" or "loss", you must promptly notify us when it is known to: 1 . You, if you are an individual; 2 . A partner, if you are a partnership; 3. Member, if you are a limited liability company; 4 . An executive officer or the "employee " designated by the Named Insured to give such notice, if you are a corporation . © 2013 Lib erty Mutual In surance Includes copyrighted material of In surance Services Office, Inc., w ith its permission . Page 6 of 7 35432931 I 57775071 I 17-18 Master Certificate I Kendra Anderson I 5 /3/20 17 1:50:18 PM (CDT) I Page 7 of 17 To the extent possible, notice to us should include : (1) How , when and where the "accident" or "loss " took place ; (2) The "insureds" name and address ; and (3) The names and addresses of any injured persons and witnesses . 20. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US SECTION IV -BUSINESS AUTO CONDITIONS, paragraph A.5., Transfer of Rights of Recovery Against Others to Us, is amended by the addition of the following: If the person or organ izat ion has waived those rights before an "accident" or "loss ", our rights are waived also . 21. HIRED AUTO COVERAGE TERRITORY SECTION IV -BUSINESS AUTO CONDITIONS , paragraph B.7 ., Policy Period , Coverage Territory , is amended by the add ition of the follow ing : f. For "autos " hired 30 days or less , the coverage territory is anywhere in the world , prov ided that the insured 's responsibility to pay for damages is determined in a "su it", on the merits , in the Un ited States , the territories and possessions of the United States of America, Puerto Rico or Canada or in a settlement we agree to . This extension of coverage does not apply to an "auto " hired , leased , rented or borrowed with a driver . SECTION V -DEFINITIONS is amended as follows : 22 . BODILY INJURY REDEFINED Under SECTION V -DEFINTIONS, definition C . is replaced by the following: "Bodily injury" means physical injury , sickness or disease sustained by a person , including mental anguish, mental injury , shock , fright or death resulting from any of these at any time . COMMMON POLICY CONDITIONS 23. EXTENDED CANCELLATION CONDITION CA 88 10 01 13 COMMON POLICY CONDITIONS , paragraph A.-CANCELLATION cond ition applies except as fo ll ows : If we cancel for any reason other than nonpayment of premium , we wi ll ma il to the first Named Insured written notice of cancellation at least 60 days before the effective date of cancellation. This prov ision does not apply in those states which require more than 60 days prior not ice of cancellation. © 20 13 Li be rt y Mutu al Insurance Incl ud es copyrig hte d ma teria l of Insurance Services Office , In c., with its perm ission . Page 7 of 7 3543 2 931 j 5777507 1 j 17-18 Master Cert ificat.e I Kendra Anderson I 5/3/2017 1:50 :1 8 PM (CDT) f Page 8 of 17 COMMERCIAL GENERAL LIABILITY CG 85 83 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED CONTRACTORS -PRODUCTS/COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Paragraph 2. under Section II -Who Is An Insured is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract or written agreement. Such person or organization is an additional insured but only with respect to liability for "bodily injury" or "property damage": 1. Caused by "your work" performed for that additional insured that is the subject of the written contract or written agreement; and 2. Included in the "products-completed operations hazard ". However: a) The insurance afforded to such additional insured only applies to the extent permitted by law; and b) If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured The insurance provided by this endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property damage". We have no duty to defend an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured as required in Paragraph b. of Condition 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit under Section IV -Commercial General Liability Conditions . B. With respect to the insurance provided by this endorsement, the following are added to Paragraph 2. Exclusions under Section I -Coverage A -Bodily Injury And Property Damage Liability: This insurance does not apply to: 1. "Bodily injury" or "property damage" that occurs prior to you commencing operations at the location where such "bodily injury" or "property damage" occurs . 2. "Bodily injury" or "property damage" arising out of the rendering of, or the failure to render , any professional architectural, engineering or surveying services including: CG 85 83 0413 a. The preparing, approving or failure to prepare or approve, maps, shop drawings , opinions, reports, surveys, field orders , change orders or drawing and specifications; and b. Supervisory, inspection , architectural or engineering activities. © 2013 Liberty Mutual Insurance Includes copyrighted material of Insurance Services Office, Inc., with its permission . Page 1 of 2 C. With respect to the insurance afforded by this endorsement , exclusion I. Damage To Your Work of Paragraph 2. Exclusions under Section I -Coverage A-Bodily Injury And Property Damage Liability is rep laced by the following : I. Damage To Your Work "Property damage" to "your work" arising out of it or any part of it and included in the "products- completed operations hazard ". D. With respect to the insurance afforded to these add itional insureds , the following is added to Section II - Limits of Insurance: If coverage prov ided to the additional insured is required by a contract or agreement , the most we will pay on behalf of the additional insured is the amount of insurance : 1. Required by contract or agreement ; or 2. Available unde r the app li cab le Lim its of Insurance shown in the Declaration. whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations . E. With respect to the insurance afforded by this endorsement, Section IV -Commercial General Liability Conditions is amended as follows: 1. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claims Or Suit: An add itional insured under th is endorsement will as soon as practicable : a. Give written notice of an "occurrence " or an offense that may result in a claim or "suit" under th is insurance to us ; b. Tender the defense and indemnity of any claim or "suit" to all insurers whom also have insurance available to the additional insured ; and c. Agree to make ava ilable any other insurance wh ich the additional insured has for a loss we cover under this Coverage Part. d. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured. 2. Paragraph 4. of Section IV -Commercial General Liability Conditions is amended as follows : CG 85 83 04 13 a. The follow ing is added to Paragraph a. Primary Insurance: If an additional insured's policy has an Other Insurance provision making its policy excess , and you have agreed in a written contract or written agreement to provide the additional insured coverage on a primary and noncontributory basis , this policy shall be primary and we will not seek contribution from the additional insured's pol icy for damages we cover . b. The following is added to Paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease , fa c ilities re ntal contract or agreement, an equip ment renta l or lease contract or agreement , or perm it issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the add itional insured is designated as a Named Insured . Regardless of the w ritten agreement be twe en you and an add itional insu red , th is insurance is excess over any other insurance whether primary, excess , contingent o r on any other basis for which the additional insured has been added as an additional insured on other policies. © 20 13 Li bert y Mutual Insura nce In clu des copy rig hted mate ri al of Insuran ce Services Offi ce , Inc., w ith it s pe rmiss io n. Page 2 of 2 COMMERCIAL GENERAL LIABILITY CG 88 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY EXTENSION This endorsement modifies insurance provided under the following : COMMERCIAL GENERAL LIABILITY COVERAGE PART SUBJECT NON -OWNED AIRCRAFT NON-OWNED WATERCRAFT PROPERTY DAMAGE LIABILITY-ELEVATORS EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) MEDICAL PAYMENTS EXTENSION EXTENSION OF SUPPLEMENTARY PAYMENTS-COVERAGES AAND B A DDITIONAL INSUREDS -BY CONTRACT, AGREEMENT OR PERMIT PRIMARY AND NON-CONTRIBUTORY -ADDITIONAL INSURED EXTENSION ADDITIONAL INSUREDS -EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" WHO IS AN INSURED-INCIDENTAL MEDICAL ERRORS/MALPRACTICE AND WHO IS AN INSURED - FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT LIBERALIZATION CLAUSE BODILY INJURY REDEFINED EXTENDED PROPERTY DAMAGE WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU © 2013 Liberty Mutua l Ins urance CG88100413 In cl udes copy ri g hted ma teria l of Ins ura nce Serv ices Office, In c., with its pe rmi ss ion. 35432931 I 57775071 I 17-18 Master Certificate J Kendra Anderson I 5/3/2017 1:50:18 PM (CDT) J Page 9 of 17 2 2 2 3 3 3 5 6 6 7 7 7 7 7 8 8 Page 1 of 8 With respect to coverage afforded by this endorsement , the provisions of the policy apply unless modified by the endorsement. A. NON-OWNED AIRCRAFT Under Paragraph 2. Exclusions of Section I -Coverage A -Bodily Injury And Property Damage Liability, exclusion g. Aircraft , Auto Or Watercraft does not apply to an aircraft provided : 1. It is not owned by any insured; 2. It is hired , chartered or loaned w ith a trained paid crew; 3. The pilot in command holds a currently effective certificate , issued by the duly constituted authority of the United States of America or Canada , designating her or him a commercial or airline pilot; and 4. It is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the insured other valid and collectib le insurance , whether pr imary, excess (other than insurance written to apply specifically in excess of this policy), contingent or on any other bas is , that would also apply to the loss covered under this provision. B. NON-OWNED WATERCRAFT Under Paragraph 2. Exclusions of Section I -Coverage A -Bodily Injury And Property Damage Liability, Subparagraph (2) of exclusion g. Aircraft, Auto Or Watercraft is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) Less than 52 feet long; and (b) Not being used to ca rry persons or property for a charge . C. PROPERTY DAMAGE LIABILITY-ELEVATORS 1. Under Paragraph 2. Exclusions of Section I -Coverage A-Bodily Injury And Property Damage Liability, Subparagraphs (3), (4) and (6) of exclusion j. Damage To Property do not apply if such "property damage" results from the use of elevators. For the purpose of this provision, elevators do not include vehicle lifts. Vehicle lifts are lifts or hoists used in automobile service or repair operations. 2. The following is added to Section IV -Commercial General Liability Conditions, Condition 4. Other Insurance, Paragraph b. Excess Insurance: The insurance afforded by this provision of this endors ement is excess over any property insurance , whether primary, excess , contingent or on any other basis. D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) If Damage To Premises Rented To You is not otherwise excluded from this Coverage Part : 1. Under Paragraph 2. Exclusions of Section I -Coverage A -Bodily Injury and Property Damage · Liability: CG88100413 a. The fourth from the last paragraph of exclus ion j . Damage To Property is replaced by the following : Paragraphs (1 ), (3) and (4) of this exclus ion do not apply to "property damage" (other than damage by fire , lightni ng , explosion , smoke , or leakage from an automatic fire protection system) to: (i) Premises rented to you for a period of 7 or fewer consecutive days ; or (ii) Contents that you rent or lease as part of a premises rental or lease agreement for a period of more than 7 da ys. Paragraphs (1 ), (3) and (4) of this exclusion do not apply to "property damage" to contents of premises rented to you for a per iod of 7 or fewer consecut iv e days . A separate limit of insurance applies to this co verage as described in Section Ill -Limits of Insurance . © 20 13 Li be rt y Mutua l Ins urance In cl udes copy rig hted materia l of In su ra nce Serv ices Office , In c., with it s pe rmi ss ion . Page 2 of 8 35432931 I 57775071 I 17-18 Master Certificate I Kendra Anderson j 5 /3 /2017 1: 50 : 18 PM (CDT) f Page 10 of 17 b. The last paragraph of subsection 2. Exclusions is replaced by the following : Exclusions c. through n. do not apply to damage by fire , lightning, explosion , smoke or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section Ill -Limits Of Insurance. 2. Paragraph 6. under Section Ill -Limits Of Insurance is replaced by the following: 6. Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of "property damage" to: a. Any one premise: (1) While rented to you ; or (2) While rented to you or temporarily occupied by you with permission of the owner for damage by fire, lightning , explosion, smoke or leakage from automatic protection systems ; or b. Contents that you rent or lease as part of a premises rental or lease agreement. 3. As regards coverage provided by this provision D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) -Paragraph 9.a. of Definitions is replaced with the following: 9.a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke , or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with the permission of the owner, or for damage to contents of such premises that are included in your premises rental or lease agreement, is not an "insured contract". E. MEDICAL PAYMENTS EXTENSION If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided by this policy are amended as follows: Under Paragraph 1. Insuring Agreement of Section I -Coverage C -Medical Payments, Subparagraph (b) of Paragraph a. is replaced by the following: (b) The expenses are incurred and reported within three years of the date of the accident; and F. EXTENSION OF SUPPLEMENTARY PAYMENTS -COVERAGES A AND B 1. Under Supplementary Payments -Coverages A and B, Paragraph 1.b. is replaced by the following : b. Up to $3,000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies . We do not have to furnish these bonds. 2. Paragraph 1.d. is replaced by the following: d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work . G. ADDITIONAL INSUREDS -BY CONTRACT, AGREEMENT OR PERMIT 1. Paragraph 2. under Section II -Who Is An Insured is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written agreement or permit. Such person or organization is an additional insured but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused in whole or in part by: CG 8810 0413 a. Your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your on going operations for the additional insured that are the subject of the written contract or written agreement provided that the "bodily injury" or "property damage" occurs , or the "personal and advertising injury'' is committed , subsequent to the signing of such written contract or written agreement; or © 2013 Liberty Mutual Insuran ce Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 8 35432931 I 57775071 I 17-18 Master Certificate I Kendra Anderson I 5/3 /20 1 7 1: 50 : 18 PM (CDT) I Page 11 o f 1 7 b. Premises or facil ities rented by you or used by you ; or c. The maintenance , operation or use by you of equipment rented or leased to you by such person or organization ; or d. Operations performed by you or on your behalf for which the state or political subdivision has issued a permit subject to the following additional provisions : (1) This insurance does not apply to "bodily injury", "property damage ", or "personal and advertising injury'' aris ing out of the operations performed for the state or political subdivision; (2) This insurance does not apply to "bodily injury" or "property damage " included within the "completed operations hazard ". (3) Insu rance applies to premises you own , rent , or control but only w ith respect to the following hazards : a) The existence, maintenance , repair, construction, erection, or removal of advertising signs , awnings , canopies , cellar entrances , coal holes , driveways, manholes , marquees , hoist away openings , sidewalk vaults , street banners , or decorations and similar exposures; or (b) The construction, erection, or removal of elevators; or (c) The ownership , maintenance , or use of any elevators covered by this insurance . However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is requ ired by a contract or agreement , the insuran ce afforded to such additional in sured will not be broader than that which you are required by the contract or agreement to provide for such additional insured . With respect to Paragraph 1.a. above , a person's or organization 's status as an additional insured under th is endorsement ends when: (1) All work , including materia ls , parts or equipment furnished in connection with such work , on th e project (other than service , maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed ; or (2) That portion of "your work " out of which t he injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operat ions for a principal as a part of the same project. With respect to Paragraph 1.b. above , a person 's o r organization 's status as an additional insured under this endors ement ends when their written contract or written agreement with you for such premises or fac ili ties ends . With respects to Paragraph 1.c. above , this i nsurance does not apply to any "occurrence" which ta kes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance prov ided by th is endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property dama ge". We have no duty to defend an add itional insured under this endorsement until we receive writte n notice of a "suit" by the additional insured as required in Paragraph b. of Condition 2. Duties In the Event Of Occurrence, Offense , Claim Or Suit under Section IV -Commercial General Liability Conditions. © 2013 Li be rt y Mut ua l Insura nce CG 88 10 0413 In cl ud es co pyri gh ted ma teri a l of In surance Serv ices Office , In c., with its pe rmi ss ion. Page 4 of 8 3543293 1 I 5 777507 1 I 1 7-18 Mast:.er Certificat:.e I Kendra Anderson I 5/3/2017 1:50 :1 8 PM (CDT) J Page 12 of 17 2. With respect to the insurance provided by this endorsement, the following are added to Paragraph 2. Exclusions under Section I -Coverage A -Bodily Injury And Property Damage Liability: This insurance does not apply to: a. "Bodily injury'' or "property damage" arising from the sole negligence of the additional insured. b. "Bodily injury'' or "property damage" that occurs prior to you commencing operations at the location where such "bodily injury" or "property damage" occurs . c. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render , any professional architectural, engineering or surveying services , including: (1) The preparing, approving, or failing to prepare or approve , maps, shop drawings, opinions, reports , surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection , architectural or engineering activities . This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury'' or "property damage", or the offense which caused the "personal and advertising injury'', involved the rendering of, or the failure to render , any professional architectural, engineering or surveying services . d. "Bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. e. Any person or organization specifically designated as an additional insured for ongoing operations by a separate ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS endorsement issued by us and made a part of this policy. 3. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement , the most we will pay on behalf of the additional insured is the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits of Insurance shown in the Declarations ; whichever is less . This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations . H. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. Condition 4. Other Insurance of SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: CG 88 10 0413 a. The following is added to Paragraph a. Primary Insurance: If an additional insured's policy has an Other Insurance provision making its policy excess, and you have agreed in a written contract or written agreement to provide the additional insured coverage on a primary and noncontributory basis , this policy shall be primary and we will not seek contribution from the additional insured's policy for damages we cover. © 2013 Lib erty Mutual Insurance Includes copy righted material of Insurance Services Office, Inc ., with its permission. Page 5 of 8 3543293 1 I 57775071 I 17 -18 Master Certificate I Kendra Anderson / 5 /3/20 17 1:50:18 PM (CDT) I Page 13 of 1 7 b. The following is added to Paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement , an equipment rental or lease contract or agreement , or permit issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the additional insured is designated as a Named Insured . Regardless of the written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess , contingent or on any other basis for which the additional insured has been added as an additional insured on other policies . I. ADDITIONAL INSUREDS -EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. 1. The following is added to Condition 2. Duties In The Event Of Occurrence, Offense, Claim or Suit: An additional insured under this endorsement will as soon as practicable: a. Give written notice of an "occurrence" or an offense that may result in a claim or "suit" under this insurance to us ; b. Tender the defense and indemnity of any claim or "suit" to all insurers whom also have insurance available to the additional insured ; and c. Agree to make available any other insurance which the additional insured has for a loss we cover under this Coverage Part . d. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured . 2. The limits of insurance applicable to the additional insured are those specified in a written contract or written agreement or the limits of insurance as stated in the Declarations of this policy and defined in Section Ill -Limits of Insurance of this policy, whichever are less . These limits are inclus ive of and not in addition to the limits of insurance available under this policy. J. WHO IS AN INSURED -INCIDENTAL MEDICAL ERRORS/ MALPRACTICE WHO IS AN INSURED -FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES Paragraph 2.a.(1) of Section II -Who Is An Insured is replaced with the following: (1) "Bodily injury" or "personal and advertising injury": CG 88 10 0413 (a) To you , to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), to a co-"employee" while in the course of his or her employment or performing duties related to the conduct of your business , or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse , child, parent, brother or sister of that co-"employee" or "volunteer worker" as a consequence of Paragraph (1) (a) above ; (c) For wh ich there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1) (a) or (b) above ; or (d) Arising out of his or her providing or failing to provide professional health care services . However, if you are not in the business of providing professional health care services or providing professional health care personnel to others , or if coverage for providing professional health care services is not otherwise excluded by separate endorsement , this provision (Paragraph (d)) does not apply. © 2013 Liberty Mutual Insurance Includes copyrighte d material of In su rance Services Office , In c., wi th its pe rmis sion. Page 6 of 8 35432931 J 57775071 J 1 7-18 Mast.er Cert.ificat.e I Kendra Ar1derson I 5/3/2017 1: 50 : 18 PM (CDT) I Page 14 of 17 Paragraphs (a) and (b) above do not apply to "bodily injury" or "personal and advertising injury" caused by an "employee" who is acting in a supervisory capacity for you . Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, includes the direct supervision of other "employees" of yours . However, none of these "employees" are insureds for "bodily injury" or "personal and advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to cause "bodily injury'' or "personal and advertising injury'', or caused in whole or in part by their intoxication by liquor or controlled substances. The coverage provided by provision J. is excess over any other valid and collectable insurance available to your "employee". K. NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES Paragraph 3. of Section II -Who Is An Insured is replaced by the following : 3. Any organization you newly acquire or form and over which you maintain ownership or majority interest, will qualify as a Named Insured if there is no other similar insurance available to that organization . However: a. Coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization ; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. d. Records and descriptions of operations must be maintained by the first Named Insured . No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations or qualifies as an insured under this provision. L. FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES Under Section IV -Commercial General Liability Conditions, the following is added to Condition 6. Representations: Your failure to disclose all hazards or prior "occurrences" existing as of the inception date of the policy shall not prejudice the coverage afforded by this policy provided such failure to disclose all hazards or prior "occurrences" is not intentional. · M. KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT Under Section IV -Commercial General Liability Conditions, the following is added to Condition 2. Duties In The Event of Occurrence, Offense, Claim Or Suit: Knowledge of an "occurrence", offense, claim or "suit" by an agent , servant or "employee" of any insured shall not in itself constitute knowledge of the insured unless an insured listed under Paragraph 1. of Section II -Who Is An Insured or a person who has been designated by them to receive reports of "occurrences", offenses , claims or "suits" shall have received such notice from the agent, servant or "employee". N. LIBERALIZATION CLAUSE If we revise this Commercial General Liability Extension Endorsement to provide more coverage without additional premium charge, your policy will automatically provide the coverage as of the day the revision is effective in your state . 0. BODILY INJURY REDEFINED Under Section V -Definitions, Definition 3. is replaced by the following : 3. "Bodily Injury'' means physical injury, sickness or disease sustained by a person. This includes mental anguish, mental injury, shock, fright or death that results from such physical injury, sickness or disease. © 2013 Liberty Mutual Insurance CG 88 10 0413 Includes copyrighted material of Insurance Servi ces Office , Inc ., with its permission . Page 7 of 8 35432931 I 57775071 I 17-1 8 Mascer Certificate I Kendra Anderson I 5/3 /2017 1:50:18 PM (CDT ) I Page 1 5 of 17 P. EXTENDED PROPERTY DAMAGE Exclusion a. of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the following: a. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the insured . Th is exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. Q. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US -WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU Under Section IV -Commercial General Liability Conditions, the following is added to Condition 8. Transfer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against a person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard" provided : 1. You and that person or organization have agreed i n writing in a contract or agreement that you waive such rights against that person or organization ; and 2. The injury or damage occurs subsequent to the execution of the written contract or written agreement. © 2013 Li berty Mu tual Insuran ce CG88100413 Includes copyrighted material of Insurance Services Office , Inc., wit h its permission . Page 8 of 8 3543293 1 I 57775071 I 17-18 Master Certificate I Kendra Anderson I 5 /3 /2017 1:50:18 PM (CDT) I Page 16 of 17 0 m N N M 0 - WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 03 B (Ed. 01-17) ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE OFFICERS AND DIRECTORS COVERAGE / EXCLUSION-CALIFORNIA If the employer named in Item 1 of the Information Page is a quasi-public applies to all officers and members of boards of directors while rendering for pay, as employees , except those excluded below who individually corporation 's issued and outstanding stock . or private corporation , this policy actual service for the corporation own at least 15 percent of the The insurance under this policy is limited as follows: It is AGREED that , anything in this policy to the contrary notwithstanding , this policy DOES NOT INSURE: Officers and Directors Excluded Timothy Raney Title CEO Nothing in this endorsement shall be held to vary , alter , waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated . Nothing elsewhere in this policy shall be held to vary , alter, waive or limit the terms , conditions , agreements or limitations in this endorsement. It is further agreed that "remuneration" when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing . FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS RE- QUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENAL TIES (Labor Code Section 3710.1, et seq.). Issued by Ohio Security Insurance Company 19291 For attachment to Policy No . XWS (18) 57 77 50 71 Effective Date Issued to RANEY PLANNING & MANAGEMENT , INC. WC 04 03 03 B (Ed . 01-17) © 2016 Workers ' Compensation Insuran ce Rating Bureau of California. All Rights Reserved . Premium $ N M 0 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA WC 99 06 79 (Ed . 01-13) We have the right to recover our payments from anyone liable for an injury covered by this policy . We will not enforce our right against the person or organization named in the Schedule . (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us .) You must maintain payroll records accurately segregating the remuneration of your employees while en - gaged in the work described in the Schedule . The addit ional premium for th is endorsement is $ 2 5 o . o o Person or Organization ALL PERSONS OR ORGANIZATIONS ANY Job Description REQUIRED BY WRITTEN CON TRACT PRIOR TO THE ACCIDE NT OR LOSS Schedule This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy Effect ive 05 /01/2017 State Endorsement No . 0004 Premium ~ Policy No . X WS (18) 57 77 50 7 1 Insu red RANE Y PL A NNING & MANAGEMENT , INC. Insurance Company Ohio Security Insurance Company 19291 Co unters igned by --------- WC 99 06 79 (Ed . 0 1-1 3) © 20 13 Lib erty Mutual Insuran ce Inc lud es co pyr ighted material of WCIRB ,w ith its perm iss io n. ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD NMATA Wayne Enke 05/08/2018 RANEYPLANN A BAS57775071 A XWS57775071 A BKS57775071 1,000,000 1,000,000 1,000,000 4,000,000 2,000,000 4,000,000 15,000 500,000 2,000,000 1,000,000 X X X X 05/01/2018 05/01/2019 05/01/2018 05/01/2019 05/01/2018 05/01/2019 Project Name: Bubb Road IS/MND City of Cupertino, its City Council, officers, officials, employees, agents, servants and volunteers are to be covered as additional insureds with respect to liability arising out of work or operations performed by or on behalf of Contractor including materials, parts or equipment furnished in connection with such work or operations. GDI Insurance Agency, Inc. City of Cupertino 10300 Torre Avenue Cupertino, CA 95014 Raney Planning & Management 1501 Sports Dr Sacramento, CA 95834 Liberty Mutual Insurance Company 23043 X This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGEPART 2013Liberty Mutual Insurance Includes copyrighted material of InsuranceServices Office, Inc.,with its permission . Paragraph under is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract or written agreement. Such person or organization is an additional insured but only with respect to liability for "bodily injury" or "property damage": Caused by "your work" performed for that additional insured that is the subject of the written contract or written agreement; and Included in the "products-completed operations hazard". However: The insurance afforded to such additional insured only applies to the extent permitted by law; and If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured The insurance provided by this endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property damage". We have no duty to defend an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured as required in Paragraph of Condition under With respect to the insurance provided by this endorsement, the following are added to Paragraph under This insurance does not apply to: "Bodily injury" or "property damage" that occurs prior to you commencing operations at the location where such "bodily injury" or "property damage" occurs. "Bodily injury" or "property damage" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services including: The preparing, approving or failure to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawing and specifications; and Supervisory, inspection, architectural or engineering activities. 2013Liberty Mutual Insurance Includes copyrighted material of InsuranceServices Office, Inc.,with its permission . With respect to the insurance afforded by this endorsement, exclusion of Paragraph under is replaced by the following: "Property damage" to "your work" arising out of it or any part of it and included in the "products- completed operations hazard". With respect to the insurance afforded to these additional insureds, the following is added to If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: Required by contract or agreement; or Available under the applicable Limits of Insurance shown in the Declaration. whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declaratio ns. With respect to the insurance afforded by this endorsement, is amended as follows: The following is added to Paragraph An additional insured under this endorsement will as soon as practicable: Give written notice of an "occurrence" or an offense that may result in a claim or "suit" under this insurance to us; Tender the defense and indemnity of any claim or "suit" to all insurers whom also have insurance available to the additional insured; and Agree to make available any other insurance which the additional insured has for a loss we cover under this Coverage Part. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured. Paragraph of is amended as follows: The following is added to Paragraph If an additional insured’s policy has an Other Insurance provision making its policy excess, and you have agreed in a written contract or written agreement to provide the additional insured coverage on a primary and noncontributory basis, this policy shall be primary and we will not seek contribution from the additional insured’s policy for damages we cover. The following is added to Paragraph When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreement, or permit issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the additional insured is designated as a Named Insured. Regardless of the written agreement between you and an additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional insured has been added as an additional insured on other policies. 05/01/2018 0008 XWS (19) 57 77 50 71 RANEY PLANNING & MANAGEMENT, INC. Ohio Security Insurance Company 19291 (Ed. 01-13) (Ed. 01-13) 2013Liberty Mutual Insurance Includes copyrighted material of WCIRB,with its permission. We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while en- gaged in the work described in the Schedule. The additional premium for this endorsement is $ . This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective Endorsement No. Policy Effective Premium State Policy No. Insured Insurance Company Countersigned by ___________________